Virtual Reality and Stress Management: A Systematic Review

Amidst the growing prevalence of chronic stress and its potential negative impacts on mental health, this review explores the use of virtual reality (VR) as a stress management solution, aiming to assess its viability and effectiveness in this context. A comprehensive search was conducted on MEDLINE, PsycINFO, and Embase from inception until February 2024. Eligible studies were primary research papers that focused on the use of VR as an intervention to mitigate psychological stress and/or distress. We included studies where the assessment of stress levels primarily relied on self-report measures. A total of 50 studies involving 2885 participants were included in our systematic review. VR-based interventions varied across studies, implementing tools such as cognitive behavioural therapy, exposure therapy, mindfulness and relaxation, repetition tasks, and psychoeducation. The reviewed studies yielded mixed results; however, a strong indication was present in highlighting the promising potential of VR-based interventions. Many studies observed a decrease in psychiatric symptoms in participants and reported increased quality of life. Various studies also found VR to be a valuable tool in promoting stress reduction and relaxation. VR was proven useful in exposing participants to stressors in a safe, controlled way. These potential benefits appear to come with no risk of harm to the participants. Although the findings are heterogenous, there is sufficient evidence supporting the use of VR for stress management across a range of contexts and populations. Overall, VR appears to be a generally low-risk, feasible intervention for those struggling with stress.


Introduction And Background
In our rapidly evolving modern society, the issue of chronic stress has risen to a significant prominence.Persistent stress poses a significant challenge in our modern, fast-paced society.The constant influx of information urging us to take action can make it increasingly difficult to quiet our minds [1].When faced with environmental stressors, our body responds with physiological changes, such as an increased heart rate due to heightened activity in the sympathetic nervous system [2].After the stressor subsides, the parasympathetic branch of the autonomic nervous system takes over, restoring balance to the body [3].While this mechanism is beneficial when exiting a stressful situation, it becomes problematic in our current reality where individuals frequently encounter stressors, resulting in a chronic state of imbalance [2,3].The stress-vulnerability model proposes that the outcome of a stressful situation, whether it remains within a manageable threshold or leads to mental health challenges, hinges on the intricate interplay between the experienced stress level and an individual's capacity to cope with it-commonly referred to as their vulnerability [4].It is noteworthy that while stress is frequently linked with various psychiatric disorders, including but not limited to anxiety disorders, depressive disorders, and posttraumatic stress disorder (PTSD), the relationship between stress and these conditions is complex [5].
Stress often exacerbates or triggers symptoms in individuals predisposed to such disorders due to a complex interplay of genetic, environmental, and psychological factors [6].Research indicates a potential involvement of the hypothalamic-pituitary-adrenal (HPA) axis in the genesis of major psychiatric conditions such as depression, mania, psychosis, and anxiety disorders [7].Elevated stress levels prompt an upsurge in cortisol production, and persistent hypercortisolemia contributes to the development of glucocorticoid receptor tolerance [8].This alteration further impacts the hippocampus, a brain region abundant in corticosteroid receptors [9].Perturbations in hippocampal function can lead to inappropriate emotional responses, and variations in hippocampal volume have been observed in diverse psychiatric disorders, including schizophrenia, PTSD, borderline personality disorder, and depression [10,11].
Understanding the intricate interplay between stress, fear, anxiety, and other related constructs is essential in comprehending the complexities of human emotional and physiological responses.Stress, often triggered by external pressures or internal challenges, can evoke fear and anxiety as adaptive responses aimed at coping with perceived threats [12].Fear arises in response to immediate danger, activating the body's fightor-flight response, while anxiety manifests as apprehension or worry about potential future threats [13].These constructs share common neural circuits and physiological pathways, including the amygdala and the HPA axis, illustrating their interconnected nature [12][13][14].Moreover, chronic stress and anxiety can exacerbate each other, leading to detrimental effects on mental health and overall wellbeing [14].
The American Psychological Association reports that 76% of surveyed US adults are negatively impacted in some way by the stress they experience.It was also reported that 27% of the surveyed adults stated they are unable to function due to the stress they experience [15].According to the UK National Institute for Health and Clinical Excellence (NICE), enhancing mental health management at work, which involves stress prevention, early intervention, and problem identification, could potentially reduce productivity losses by up to 30% and lead to annual savings of £250,607 in a company with 1000 employees [16].Therefore, the imperative for effective stress treatments has never been more pressing.Stress, often triggered by factors ranging from work-related pressures to personal challenges and societal expectations, exerts profound adverse effects on both mental and physical well-being [17].Chronic stress is closely linked to an array of conditions, including psychiatric disorders, cardiovascular diseases, and compromised immune systems [5,18].Unearthing efficacious stress management strategies, therapies, and interventions is paramount to enhance individuals' holistic wellness, elevate productivity, and alleviate the strain on healthcare systems.By devising approaches that directly target stress management, we have the potential to empower individuals to lead lives marked by improved health and greater contentment, thereby nurturing a society characterized by enhanced resilience.
Virtual reality (VR) has emerged as a captivating solution for stress management, offering a unique avenue to unwind and find respite from the demands of modern life [19].VR has also proven to be effective in alleviating symptoms and improving outcomes for individuals dealing with both psychiatric conditions such as PTSD and various health conditions including pain management [20,21].By immersing users in visually stunning and emotionally engaging environments, VR provides a sensory escape that can effectively lower stress levels and promote relaxation [22].From serene nature scenes to guided mindfulness exercises, VR offers a versatile range of experiences tailored to individual preferences [19].The recognition of stress's pervasive influence underscores the imperative for comprehensive stress management strategies.However, the multifaceted nature of stress, ranging from daily stressors to those associated with psychiatric disorders, necessitates a nuanced approach to its mitigation.To address this complexity, this review seeks to explore various forms of stress and their related management within a unified framework, particularly focusing on the role of VR.Despite its potential, a significant gap in knowledge exists regarding the sustained impact of VR on stress management.As VR continues to integrate into wellness practices and stress-related disorders continue to rise in prevalence, further research and exploration are crucial to fully understand its role in providing effective and sustainable stress relief.The objective of this review is to systematically synthesize the current literature to determine the efficacy and viability of VR in stress management.The objective of this review is to systematically synthesize the current literature to determine the efficacy and viability of VR in treating stress and related disorders.

Search Strategy
A comprehensive search was conducted on MEDLINE, PsycINFO, and Embase through OVID from inception until February 23, 2024.This systematic review was completed based on the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Statement [23].We used the following keywords [Mesh] to identify relevant articles: (Stress*, Psychological) OR (life OR psychologic* OR emotion* OR Psychological Distress OR Rehabilitation OR Treatment* OR Intervention* OR Prevention) AND virtual reality OR VR.There was no restriction on the year of publication.Google Scholar and included studies' references were evaluated to avoid missing relevant articles.

Study Eligibility Criteria
All articles were imported to the Covidence platform (covidence.org) for the screening process.Two reviewers independently evaluated titles, abstracts, and full-text articles from the electronic search based on predefined inclusion and exclusion criteria to pinpoint potentially eligible articles.Any disagreements between the two reviewers were resolved through discussion.Studies eligible for the purposes of this review were primary research papers in the English language that focused on the use of VR as an intervention to mitigate psychological stress and/or distress.In the context of this study, VR was defined as a technology that immerses users in computer-generated environments through various implementations.These implementations encompass head-mounted displays (HMDs) for immersive visual experiences, simulators for professional training, mobile VR for accessibility and web-based VR for browser-driven experiences.In contrast, web-based VR for browser-driven experiences involves interactive environments accessed through web browsers, allowing users to navigate and interact with virtual content in real-time, while 360° videos are prerecorded videos capturing panoramic scenes that users can view from any angle but do not offer interactive elements.Study populations included healthy and clinical samples of adults and older adults (aged 18+).Eligible studies must also have incorporated a measure of psychological stress and/or distress before and after the VR intervention with the use of 1) formally recognized assessment tools (e.g., perceived stress scale (PSS)); or 2) self-report; or 3) clinical assessments.Studies that use physiological measurements (e.g., heart rate variability and skin conductance) as the only measure of stress were excluded.Our rationale for primarily including studies that relied on self-report measures stems from the nature of the interventions evaluated in our review.Given the immersive and experiential nature of VR interventions, self-report measures are often considered the most appropriate and practical method for assessing stress levels and psychological distress experienced by participants during VR sessions.While physiological measures are valuable in stress research, their incorporation into VR interventions is less common and may not align with the specific focus of our review.We also excluded letters/correspondences, animal studies, editorials, systematic reviews, meta-analyses, commentary, case studies, case series, observational studies and conference abstracts.

Data Extraction
Two reviewers independently read the full text of eligible studies and extracted the following data: author, year of publication, country, apparatus, outcome measure, study design, topic results, participants, and conclusion.

Risk of Bias Assessment
We employed the Cochrane Handbook for Systematic Reviews of Interventions to assess the quality of eligible randomized trials.Our evaluation encompassed five domains: potential bias from random sequence generation, allocation concealment, blinding of study participants, incomplete outcome data, and selective reporting [24].The Newcastle-Ottawa Scale (NOS) was used to assess potential bias in observational studies.The NOS allowed us to evaluate the quality of these studies based on three key domains: selection of study groups, comparability of groups, and assessment of outcome.This comprehensive approach enabled a thorough examination of bias and methodological rigour within the realm of observational research [25].The risk of bias assessment of included studies is indicated in Supplementary materials.

Search Results
The study flow diagram is indicated in Figure 1.A total of 1346 studies were identified through database searching.After removing the duplicates (n = 317), two reviewers independently scanned the titles and abstracts of 1029 papers.The full texts of 75 articles were screened for eligibility.Twenty-five articles were excluded for the following reasons: not a primary research paper (n = 12), non-relevant outcomes (n = 7), VR was utilized as a part of the procedure rather than an intervention on its own (n = 1), wrong indication and measures (n = 5).Eventually, 50 studies met the inclusion criteria involving 2885 participants and were included in our systematic review.Risk of bias assessment results are indicated in Supplementary materials.The characteristics of included studies included in this review are summarized in Table 1.Participants engaged in VR speech rehearsals, leading to significant decreases in self-reported anxiety, avoidance scores, distress, and negative self-evaluation [29].Freeman et al. assessed distress reduction in participants with persecutory delusions during VRE therapy, finding gradual distress reduction across sessions, particularly in the group undergoing VR cognitive therapy [30].Hoch et al. investigated stressreduction techniques in an online virtual world.The authors designed a translated version of an existing 8week relaxation response-based resilience programme in VR.The general trend was toward improvement using the PSS and the Symptom Checklist 90-Revised (SCL-90-R) [31].

Richesin et al. compared stress management interventions involving classic 2D
art-making, novel 3dimensional (3D) VR art-making, and a non-artistic VR CG, finding significant decreases in negative affect, state anxiety, trait anxiety, and perceived stress post-VR intervention [32].Kothgassner et al. examined the impact of virtual social support on stress levels, reporting that avatar and real social support reduced stress and promoted prosocial behaviours compared to agent-based or no-support conditions [33].Villani et al. evaluated stress management techniques using VR, video, and audio mediums, observing significant reductions in stress in the VR condition compared to video and audio, indicating lower physiological arousal [34].
Tan et al. investigated stress management among participants with mental disorders using a VR programme called V-DESSERTS, reporting lower subjective stress, higher perceived relaxation, and greater improvement in knowledge compared to the control group [35].Aganov et al. explored the effectiveness of Pure Purr technology in reducing stress levels among healthy adults, finding enhanced parasympathetic activity and decreased sympathetic activity with the investigational device compared to the sham device.Moreover, State-Trait Anxiety Inventory (STAI) scores decreased after a 5-minute VRE to either headset [36].Zhang et al. investigated VR-Managing Cancer And Living Meaningfully (CALM) intervention's impact on stress outcomes among breast cancer patients undergoing chemotherapy, finding significant reductions in distress levels, anxiety, and depression scores [37].Espinoza et al. aimed to promote emotional well-being using VR interventions among adult cancer patients, reporting significant reductions in anxiety and depression levels post-intervention, along with increased happiness levels [38].Schneider et al. explored the efficacy of VR distraction intervention in alleviating chemotherapy-related symptom distress among older women with breast cancer, finding a significant reduction in anxiety scores immediately after treatment with VR [39].However, in the other study, Schneider et al did not find any significant differences in measures of symptom distress immediately following chemotherapy and or at two days follow-up [40].Chirico et al. assessed the impact of VR and music therapy on anxiety levels in breast cancer patients undergoing chemotherapy, observing significant reductions in stress, anxiety and negative mood states post-intervention [41].Fabi et al. investigated distraction therapy using VRE in breast or ovarian cancer patients undergoing chemotherapy, reporting significant reductions in state anxiety scores in the VRE group compared to controls immediately after and within 48 hours of chemotherapy [42].These studies collectively underscore the promising role of VR interventions in alleviating stress and promoting emotional well-being across diverse populations, ranging from individuals with mental disorders to cancer patients undergoing chemotherapy and healthy adults.
Gullo et al. evaluated the effectiveness of VR-augmented self-hypnosis in reducing anxiety during peripheral endovascular interventions, finding significantly lower anxiety after the procedure in the virtually augmented self-hypnosis group compared to treatment as usual [43].Yang et al. explored the impact of preoperative VRE to 3D reconstructed magnetic resonance images on anxiety reduction in patients undergoing arthroscopic knee surgery, reporting significantly lower surgery-related anxiety and higher satisfaction in the VR group compared to the non-VR group [44].Ganry et al. observed a significant decrease in anxiety scores after immersive VR experience among individuals with anticipated high stress levels during surgery [45].Brown et al. investigated the impact of VR interventions on stress outcomes in chronic low back pain patients undergoing spinal injections, finding potential benefits of audiovisual interventions in reducing anxiety during medical procedures [46].Almedhesh et al. assessed the impact of VR on maternal anxiety and stress levels during elective caesarean section, reporting significantly reduced stress and anxiety levels in the VR intervention group compared to controls [47].Vieira et al. examined the effect of a VR exercise programme on stress levels in patients undergoing cardiac rehabilitation, observing a significant reduction in stress levels compared to the control group [48].Rutkowski et al. investigated the effectiveness of VR-led pulmonary rehabilitation in reducing stress levels in patients with Post-Acute Sequelae of SARS-CoV-2 infection, finding significant reductions in stress levels post-rehabilitation [49].Jóźwik et al. reported significant improvements in stress levels among coronary heart disease patients undergoing VR therapy compared to standard care [50].These findings collectively highlight the potential of VR interventions as effective tools for managing anxiety and reducing stress across various medical procedures and patient populations.
Lewandowski et al. explored the impact of VR immersion during vedolizumab infusion on stress outcomes in patients with inflammatory bowel disease, finding significant improvements in stress-related outcomes in the VR group compared to the control group [51].Anderson et al. observed significant reductions in stress levels during exposure to natural VR scenes compared to control scenes, as indicated by outcome measures and subjective mood assessments [52].Zolfaghari et al. reported notable reductions in distress and negative affect post-VR intervention among young patients in emergency departments [53].Shah et al. found significant reductions in stress, depression, and anxiety levels post-VR intervention among inpatients with major depressive disorder and bipolar disorder [54].These studies collectively suggest that VR interventions hold promise in effectively managing stress across various populations and settings.Wang et al. investigated the impact of virtual environments on stress relief in individuals with GAD [55].Seventy-seven participants were randomly assigned to either a virtual nature (VN) or virtual abstract painting (VAP) group.Both groups engaged in 20-minute cycling sessions in VR environments.Post-exercise alpha values, indicating relaxation, were significantly higher in the VN group compared to the VAP group.While perceived stress scores were higher post-exercise, the VN group reported greater stress relief than the VAP group.Moreover, the VN group showed significantly higher levels of restorative quality and satisfaction after the intervention, suggesting that exposure to VR natural environments may offer superior stress relief and enhance psychological well-being in individuals with GAD compared to abstract paintings [55].Afifi et al. conducted a study involving 21 family dyads from a senior living community to assess the effects of VR sessions on stress outcomes for older adults and their family members [56].Participants engaged in VR sessions designed to evoke positive memories and experiences, while self-report measures were used to evaluate stress levels.Results indicated significant reductions in perceived stress for both older adults and family members following the VR sessions [56].Additionally, family members reported decreased caregiver burden, highlighting the potential benefits of VR interventions in mitigating stress among older adults and their caregivers.These findings suggest that VR technology may offer a promising approach to addressing stress-related challenges in ageing populations and their families.
Szczepanska-Gieracha et al. examined the effects of VR therapy on stress outcomes in 34 patients undergoing cardiac rehabilitation (CR) for coronary artery disease (CAD) [57].The study compared VR therapy with standard relaxation techniques.Results revealed significant reductions in anxiety, depression, and perceived stress among patients receiving VR therapy compared to the control group [57].These findings suggest that VR therapy may effectively alleviate stress in CAD patients undergoing CR, potentially enhancing their overall psychological well-being and treatment outcomes.
In another study by Veling et al., psychiatric patients undergoing stress-reducing interventions, including the VRelax app and standard relaxation exercises, experienced significant reductions in negative affective states and improvements in positive affective states.VRelax demonstrated a larger beneficial effect on negative affective states compared to standard relaxation exercises, with short-term effects including reductions in depression and anxiety symptoms [58].These findings underscore the potential of VR-based interventions like VRelax in alleviating stress outcomes across various psychiatric disorders.Blum et al. investigated the effects of standard heart rate variability biofeedback (Standard-BF) and VR-based heart rate variability biofeedback (VR-BF) treatments on relaxation in healthy participants [59].Both groups received a single 10-minute session of heart rate variability biofeedback involving slow diaphragmatic breathing.The VR-BF group experienced a virtual beach scenery while practising biofeedback, while the Standard-BF group received abstract graphical feedback.Subjective relaxation was measured using the STAI.Results showed that both treatments increased relaxation, as indicated by reduced STAI scores after each stressor and a reduction in scores from before to after the treatment session [59].Overall, the study partially confirmed the hypothesis that VR-BF would lead to greater relaxation compared to Standard-BF.Pallavicini et al. aimed to test the INTREPID project approach in a Phase II randomized controlled trial with GAD patients [60].Treatment groups underwent eight sessions of VR-based treatment with or without biofeedback.Results showed significant improvements in stress outcomes across groups.Participants reported high satisfaction with the treatment [60].Finally, Venuturupalli et al. conducted a study on 20 participants with chronic autoimmune disorders [61].They underwent VR sessions with guided meditation (GM) and respiratory biofeedback (BFD).Both interventions significantly reduced pain, stress and anxiety levels.GM was more effective in reducing anxiety.The order of intervention did not significantly affect outcomes [61].Overall, the study highlighted the potential of VR interventions in managing stress outcomes in patients with chronic autoimmune disorders.
Two RCTs and a pilot study [62,63] with a within-subject design [64] evaluated the efficacy of a VR-based self-help intervention "COVID Feel Good" in Germany, Iran, and Italy, respectively.They used various scales to measure outcomes such as stress, depression, and anxiety [62][63][64] In general, these interventions led to significant improvements in stress, depression, and perceived stress, but not in hopelessness [62][63][64].Another study examined the feasibility of an ICU-specific VR intervention [65].One month after the intervention, fewer participants in the VR group reported probable anxiety compared to the control group.However, anxiety scores were not significantly lower in the VR group at this point or at the three-month follow-up.
Regarding stress among healthcare workers during COVID-19, two studies explored VR interventions [66,67].One study showed a significant reduction in stress among frontline healthcare workers after a short VR simulation of a nature scene [66].The other study involved healthcare professionals viewing nature-based content.Concerning anxiety, the VR walk in the woods was the most effective in diminishing anxiety from pre-to post-intervention, followed by VR forest of focus, computer screen forest of focus, and computer screen walk in the woods.All groups experienced a decrease in anxiety, but no significant differences between the groups [67].These studies underscore the potential of VR-based interventions in addressing mental health challenges during the COVID-19 pandemic and in ICU settings.
The study conducted by Ho et al. aimed to evaluate the effects of a VR intervention on stress-related outcomes among factory workers in Taiwan [68].The VR intervention involved watching nature-based VR videos for 30 minutes once a week for 12 weeks during the workers' break time, while the comparison group received no interventions.The results showed significant improvements in psychological measures such as distress, anxiety, depression, and positive affect in the VR group compared to the comparison group [68].These findings suggest that the VR intervention had beneficial effects on stress reduction among factory workers.The study conducted by Weitzman et al. focused on evaluating the effects of a VR-GM intervention on burnout among Otolaryngology residents [69].Participants were randomized into two groups, with one group undergoing the VR intervention using a smartphone app for 10 minutes weekly, while the other group served as the control [69].Results showed a significant decrease in the emotional exhaustion subscale score after the intervention, indicating reduced burnout.Subgroup analysis revealed that the male gender was associated with a decrease in EE subscale score, whereas the female gender was not.Overall, participants rated the VR-GM as enjoyable and easy to use, with potential usefulness as a stress management tool.
The study conducted by O'Gara et al. investigated the acceptability and feasibility of a novel intervention utilizing VR among cancer patients [70].The findings revealed satisfactory acceptability of the intervention, with most participants completing all three sessions.Further analyses indicated improvements in mood and a reduction in stress levels following the intervention sessions.Overall, the study provided valuable insights into the feasibility and acceptability of the VR intervention among cancer patients, suggesting its potential utility in reducing stress levels and enhancing psychological well-being in this population [70].The study by Vaquero-Blasco et al. examined the impact of a 360-degree VR relaxation experience on stress levels in healthy participants [71].The session involved EEG recording and consisted of phases: initial resting state, a stress-inducing arithmetic test, 5-minute VR relaxation with scenarios such as beach and space, and a final resting state.Results indicated a significant reduction in self-reported stress levels post-VR relaxation, corroborated by EEG biomarkers such as relative gamma showing an overall decrease during the relaxation phase.However, individual responses varied, with some participants showing direct RG-stress relationships and others inverse [71].
Chiu et al. conducted a study to assess the impact of a VR intervention on preoperative anxiety among patients scheduled for elective surgery.The study aimed to recruit 90 participants but faced challenges due to the COVID-19 pandemic [72].Participants were randomized into intervention and control groups, with the intervention group receiving standard care along with a VR-based perioperative journey experience.Results showed significant reductions in preoperative anxiety and stress levels among the intervention group compared to the control group, along with higher post-surgery satisfaction levels [72].
Cheng et al. conducted a quasi-experimental trial to assess the effectiveness of a combined intervention in reducing perceived stress and enhancing happiness, sleep quality, meditation experience, and life satisfaction among institutionalized older adults in Taiwan [73].The results revealed significant improvements in happiness, perceived stress, sleep quality, meditation experience, and life satisfaction in the experimental group compared to the control group [73].Gaggioli et al. conducted a multicentric randomized block-controlled trial involving teachers and nurses highly exposed to psychological stress to evaluate the efficacy of stress management interventions [74].Participants were randomly assigned to an Experimental Group (EG), Control Group (CG), or Wait-List group (WL).The EG received stress management training using immersive VR scenarios, biosensors, and mobile phone applications, while the CG received traditional cognitive behavioural techniques without technology.Results showed significant reductions in chronic anxiety and perceived stress in both treatment groups, with greater improvements in the EG [74].
Dings et al. conducted a non-randomized controlled trial to investigate the effectiveness of two-dimensional (2D) video glasses and VR glasses in reducing pain and anxiety during vasectomy procedures [75].A total of 176 patients scheduled for vasectomy were sequentially divided into three groups: Control, 2D video glasses, and VR glasses.Patients in the VR group experienced significantly higher levels of anxiety during the procedure compared to the control and 2D video glasses groups.Additionally, patients without prior hospitalizations reported higher levels of pain compared to those with prior hospitalizations.The study suggests that while 2D video glasses did not reduce pain or anxiety, VR glasses may increase anxiety levels during vasectomy procedures [75].

Discussion
In this study, we systematically reviewed and evaluated studies that assessed the effect of VR for stress management The purpose of this systematic review was to comprehensively examine the existing body of literature on the use of VR for stress management and contribute to the understanding of VR's potential role as a viable and efficacious tool for stress reduction.The results of the included studies suggest that VRE is an effective tool for stress management.Stress is a highly prevalent issue in today's society and is a significant contributor to the deterioration of mental well-being and human capital [76].Individuals today frequently experience forms of stress rooted in various domains of their lives, and the inability to manage such stress can potentially result in a chronic imbalance of the sympathetic nervous system as well as mental challenges or stress-related disorders [2,77].As described by the stress-vulnerability model, the outcome of stressful situations is dependent on the intricate interplay between the experienced stress level and the individual's ability to cope or their vulnerability [8].VR appears to be a generally low-risk intervention, as evidenced by the studies included in our review.While some participants may experience mild discomfort or motion sickness during VR sessions, serious adverse effects are rare.Additionally, the controlled nature of VR environments allows for careful monitoring and adjustment of stimuli to ensure participant safety.
Several studies have delved into the intricate relationship between VR and stress management within the realm of psychiatric disorders.While the results are diverse, they underscore the potential of VR as a therapeutic tool.Notably, when it comes to PTSD, VRET has yielded mixed outcomes.However, it is important to consider that the effectiveness of VR may vary depending on the specific trauma and individual responses [78] This variability highlights the need for personalized treatment approaches and further research to optimize VR-based interventions for PTSD.In addition, when paired with therapeutic techniques such as cognitive therapy, VR has demonstrated the ability to decrease psychiatric symptoms in participants experiencing psychosis or schizophrenia such as auditory verbal hallucinations, delusional conviction, distress, and depressive symptoms, while improving quality of life [30].Furthermore, in the realm of phobias and anxiety disorders, VR has showcased its ability to alleviate symptoms, particularly in scenarios such as fear of public speaking and acrophobia.These findings suggest that VR can offer a versatile platform for ET in treating various anxiety-related conditions.Nonetheless, it is essential to address challenges such as fear renewal during virtual exposure, emphasizing the importance of refining VR protocols to maximize their benefits.In the context of stress-related disorders, the comparison between VR applications and traditional cognitive behavioural therapy unveils the advantages of VR, particularly in terms of accessibility and engagement.This is crucial because individuals with mental health issues often struggle with the initiative and energy required for conventional stress-reduction methods [79].The user-friendly, low-effort nature of VR may bridge this gap and provide a more accessible route to stress management for those in need and can reduce the inconsistency of treatment delivery [80].VR technology holds promise in the domain of stress management for psychiatric disorders, but its effectiveness depends on the specific condition and individual characteristics.Ongoing research and the refinement of VR-based interventions are essential to harness the full potential of this innovative approach to improving mental health.
The results regarding the application of VR in healthcare show that this is a dynamic and promising avenue of research.VR technology offers a wide array of possibilities that have already shown significant progress in enhancing patient care and overall well-being.Notably, VR has shown to be a valuable tool in pain management, with studies consistently demonstrating its effectiveness in reducing reported pain levels through interactive experiences and GM.This approach presents an alternative to traditional pain medications, engaging patients in a more holistic manner by providing distraction-based pain relief.In the realm of cancer care, VR has made substantial strides, particularly in mitigating anxiety, depression, and fatigue among chemotherapy patients, contributing significantly to their overall quality of life and psychological well-being [42,43].This comprehensive approach to patient care acknowledges the emotional and psychological aspects of healthcare, extending beyond the purely physical.Beyond these areas, VR has found applications in various healthcare contexts, such as reducing anxiety related to medical procedures and improving rehabilitation programmes across diverse health conditions.During the COVID-19 pandemic, people were experiencing an influx of uncertainty, anxiety, and fear which can increase the risk of developing psychological distress and other mental health problems [77].VR played a role in supporting mental health, with VR-based self-help interventions effectively reducing distress, stress, and depression during times of heightened uncertainty and isolation.VR's diverse applications in healthcare highlight its potential to improve patient care across various domains, and as technology continues to advance, becomes more affordable, and research expands, VR is poised to become an increasingly essential tool in enhancing healthcare outcomes and patient experiences.
Studies examining VR and work-related stress pose an interesting consideration regarding the effectiveness of VR as a stress-reduction and practice or capacity-building tool.These studies demonstrate how VR can benefit patients and practitioners alike.VR studies in relation to work stress have uncovered the ability to reduce mental demand and effort dimensions, emotional exhaustion, anxiety, and distress among varying types of medical residents as well as factory workers [68,69].Each study reviewed in this section supports VR as a means to manage work-related stress, whether through a practice/training model or as a form of mindfulness and relaxation.In these instances, the VR intervention produced favourable results in comparison to control groups.These results further demonstrate the different potential approaches that can be taken to reduce stress and emphasize the therapeutic techniques that may be best suited to targeting specific stress-related behaviours or stress-inducing scenarios.
It's essential to consider the varying levels of stress experienced by different populations and how VR interventions may affect them differently.While our review primarily focuses on the efficacy of VR interventions in reducing stress across diverse populations and contexts, it's notable to compare the effectiveness observed in healthy participants facing daily stressors versus clinical populations experiencing more severe stress.Several studies included in our review investigated the impact of VR interventions on stress outcomes in healthy individuals facing everyday stressors.These studies consistently reported significant reductions in stress levels, indicating the potential of VR to effectively alleviate stress in this population.On the other hand, studies involving clinical populations facing more severe stress, such as patients with chronic autoimmune disorders or individuals with psychiatric disorders, also reported promising results.While both healthy participants and clinical populations may benefit from VR interventions in reducing stress, it's essential to recognize the differing levels and sources of stress experienced by these populations.Future research could further explore how VR interventions can be tailored to address the unique stressors faced by clinical populations, potentially enhancing their effectiveness in managing stress in these individuals.Furthermore, VR interventions present a versatile array of settings and durations, tailored to address specific populations and conditions.By offering immersive experiences that simulate real-life scenarios, VR enhances the effectiveness of stress management techniques.Moreover, when integrated with other therapeutic modalities such as cognitive behavioural therapy or GM, VR interventions may yield synergistic benefits.Their capacity to deliver personalized experiences and real-time feedback fosters active engagement and self-awareness among users.Additionally, VR-based interventions can be seamlessly adapted for use across various healthcare settings, from hospitals to rehabilitation centres.However, potential limitations and disadvantages must be considered, including the need for specialized equipment and trained personnel, variability in individual response to VR, and suitability concerns for certain medical conditions or sensory impairments.Addressing issues related to privacy, data security, and potential adverse effects of prolonged VR use is essential for the widespread adoption and ethical implementation of VR interventions.
In our analysis, we conducted a thorough assessment of the risk of bias across the included studies, and the findings revealed a generally low level of bias.This indicates that the studies we reviewed maintained a high standard of methodological rigour, minimizing the potential for systematic errors or inconsistencies in their results.This low risk of bias enhances the confidence in the robustness and credibility of the conclusions drawn from our analysis, providing a solid foundation for the assessment of the efficacy of VR interventions in managing stress outcomes across diverse populations and contexts.Additionally, considering the distribution of samples, we observed a diverse representation across different demographic groups, including individuals from various geographical regions and genders.However, it's essential to acknowledge the potential biases that may exist, such as the overrepresentation of certain demographic groups or cultural backgrounds, commonly referred to as WEIRD (Western, Educated, Industrialized, Rich, and Democratic) biases, and gender biases.
While our review encompasses a diverse range of populations and contexts, it's essential to acknowledge the limitations.The varied contexts in which VR has been studied for stress reduction suggest that its effectiveness may differ across domains, as evidenced by the contrasting results highlighted in our review.However, these discrepancies also present an opportunity for future research to delve deeper into unique contexts, expanding the current understanding of VR's potential in stress reduction.Moving forward, researchers should focus on identifying key factors that optimize VR-based interventions, such as determining the ideal exposure time and number of sessions required for desired outcomes.These insights are crucial for the development of more effective VR interventions in the future and should be a priority in prospective research and intervention trials.Additionally, our review has further limitations that require consideration.Firstly, there is the potential for publication bias, as we restricted our analysis to studies published in peer-reviewed journals, possibly overlooking relevant unpublished.Secondly, the variability in study quality across the included literature, with some studies lacking rigorous experimental designs or adequate control groups, introduces the possibility of bias and may impact the reliability of our conclusions.Furthermore, despite our efforts to conduct a comprehensive search across multiple databases, it is possible that relevant studies were missed, potentially limiting the scope of our review.Small number of studies, small sample size and diversity of participants is another limitation.Additionally, the exclusion of non-English language studies may have introduced language bias.Moreover, our decision not to conduct a metaanalysis due to methodological heterogeneity among the included studies means that we were unable to quantitatively assess the overall effect size of VR interventions on stress outcomes.Finally, given the rapidly evolving nature of VR technology and its applications for stress management, our review may not encompass the most recent advancements in the field.Further exploration into the long-term effectiveness of VR interventions is vital to strengthen findings.Understanding how VR integrates into clinical practice and tailoring interventions to diverse populations is crucial.

Conclusions
In conclusion, VR-based interventions maintain the ability to become extremely personalized to the user, creating a patient-centred care model that can adapt and flux along with the individual's needs.Centring care around the patient and engaging them in their care has been associated with better health outcomes and quality of life.VR allows for control, support and customization throughout the therapeutic process that may not be otherwise available, especially regarding instances such as exposure therapy, where controlling the stimuli may be impossible if not for VR technology and programming.Reports of positive participant perceptions of VR, high feasibility of VR intervention implementation, and high participant retention frequently accompanied studies implementing VR-based interventions.In cases where analysis found no notable changes in participants or differences from the control groups, researchers still appear to agree that even without statistically significant results, VR-based interventions did not cause aversive outcomes in participants.Given this information, it might be concluded that VR acts as a low-risk intervention for stress management for a wide-ranging patient demographic.

1 :
Group 1 used 2D video glasses showing a nature movie about coastlines and the sea with relaxing music.The content was displayed on a 2D Patients planned for a vasectomy (N=140 N=61 CG Patients in the VR group experienced significantly more anxiety during the procedure The VR and 2D video glasses did not Dings et al., Characteristics of included studies.Patient-Reported Outcomes Measurement Information System, FAS: Facial Anxiety Scale, HC: heart coherence, PSYRATS: Psychotic Symptoms Rating Scale, FCOR : fear of coronavirus, SRSI3: Smith Relaxation State Inventory 3, SSQ: Simulator Sickness Questionnaire, MoCA : Montral Cognitive Assessment, DASS 21: Depression, Anxiety, and Stress Scale 21; PANSS: Positive and Negative Symptom Scale; SSI-4: stuttering severity instrument 4; GAD-7: Generalised Anxiety Disorder-7 item measure; SUDs: Subjective Units of Distress; PA: positive affect; NA: negative affect; LSAS: Liebowitz Social Anxiety Scale; HAM-d: Hamilton Rating Scale for Depression; VAS: visual analog scale; VAS-A: Visual Analogue Scale for Anxiety; STAI: State-Trait Anxiety Inventory Form; PSS: Perceived Stress Scale; MINI: Mini-International Neuropsychiatric Interview; SCL-90-R: Symptom Checklist 90-Revised; GSI: Global Severity Index; ASDS-2: Adapted Symptom Distress Scale-2; PFS: Piper Fatigue Scale; STAI: Spielberger Anxiety State Inventory; SCL: Skin Conductance Level; BHS: Beck Hopelessness Scale; HADS: Hospital Anxiety and Depression Scale; SCS: Social Connectedness Scale; IES-R: Impact of Event Scale-Revised; EQ-5D: European Quality of Life, 5 dimensions; SCID-5-CV: Structured Clinical Interview for DSM-5 Disorder; WIWI: Was it Worth it Questionnaire; FACT-B: Functional Assessment of Cancer Therapy-Breast cancer patient; DT: Distress Thermometer; SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale; DASS: Depression Anxiety Stress Scale; BHS: Beck Hopelessness Scale; FAS: Flight Anxiety Situations, B-MEPS: Brief measure of emotional preoperative stress; NVFAS: novel visual facial anxiety scale; NSRS: single-item numeric stress rating scale; PQ: presence questionnaire; CALM: Cancer And Living Meaningfully

FIGURE 1 :
FIGURE 1: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.